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Methods: We used discrete event simulation modeling to compare the effect of additional physician coverage versus adding PAs on wait time, length of stay (LOS), and patients leaving without being seen.

Results: Simulation of extended physician coverage reduced wait times, LOS, and rates of leaving without being seen across acuity levels. Adding PAs reduced wait times and LOS for high-acuity visits, and slightly increased the LOS for low-acuity visits.

Conclusions: With restricted autonomy, PAs mainly benefitted the high-acuity patients. Increasing the level of PA autonomy was critical in broadening the effect of PAs to all acuity levels.

Quynh Doan is an assistant professor in the Department of Pediatrics at the University of British Columbia in Vancouver. William Hall is a research associate at the Centre for Clinical Epidemiology and Evaluation at the University of British Columbia. Steven Shechter is an associate professor in the Sauder School of Business at the University of British Columbia. Niranjan Kissoon is vice president of medical affairs at British Columbia Children's Hospital in Vancouver and a professor of acute and critical care and global child health at the University of British Columbia. In the university's School of Population and Public Health, Sam Sheps and Joel Singer are professors and Hubert Wong is an associate professor. David Johnson is a professor in the Department of Pediatrics and Pharmacology and Physiology at the University of Calgary in Calgary, Alberta. The authors have disclosed that this study received a local seeding grant from the Innovations in Acute Care and Technology cluster of the Child and Family Research Institute. Dr. Doan was also supported with a doctoral award by the Canadian Child Health Clinician Scientist Program while completing this study as part of her dissertation work.

Acknowledgment: The authors would like to thank the research student volunteers who conducted the direct observations and data collection permitting the building of the DES model.